Defense Privacy and Civil Liberties Office

U.S. Department of Defense

System of Record Notices (SORNs)

DOD Component Notice

Defense Health Agency

EDTMA 02

SYSTEM NAME:

Medical/Dental Care and Claims Inquiry Files  (November 18, 2013,  78 FR 69076)

SYSTEM LOCATION:

TRICARE Management Activity, Department of Defense, 16401 East Centretech Parkway, Aurora, CO 80011-9066, and contractors under contract to TRICARE. A listing of TRICARE contractors maintaining these records is available from the system manager.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

All individuals who seek information concerning health care (medical and dental) under TRICARE/CHAMPUS and CHAMPVA.

CATEGORIES OF RECORDS IN THE SYSTEM:

Inquiries received from private individuals for information on TRICARE/CHAMPUS and CHAMPVA, and replies thereto; congressional inquiries on behalf of constituents and replies thereto; and files notifying personnel of eligibility or termination of benefits. Information may include: name; Social Security Number (SSN); date of birth; case number; dates of treatment; medical diagnosis; Defense Enrollment Eligibility Reporting System (DEERS) data; address; telephone number; marital status; adoption information; and sponsor name.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

41 CFR 101-11.000, Federal Records and Standard and Optional Forms; 10 U.S.C. 55, Medical and Dental Care; 38 U.S.C. 1781, Medical Care for survivors and dependents of certain veterans and E.O. 9397 (SSN), as amended.

PURPOSE(S):

To maintain and control records pertaining to requests for information concerning an individual's TRICARE/CHAMPUS eligibility status, the benefits provided under programs of TRICARE/CHAMPUS and CHAMPVA and the processing of individual TRICARE/CHAMPUS and CHAMPVA claims.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSES OF SUCH USES:

In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a (b) (3) as follows:

  • To the Department of Health and Human Services and/or the Department of Veterans Affairs consistent with their statutory administrative responsibilities under TRICARE/CHAMPUS and CHAMPVA pursuant to chapter 55, 10 U.S.C. and section 613, chapter 17, 38 U.S.C.
  • To Federal, state, local, or foreign governmental agencies, and to private business entities, including individual providers of care (participating and non-participating), on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil or criminal litigation related to the operation of TRICARE/CHAMPUS.
  • To third-party contacts in situations where the party to be contacted has, or is expected to have, information necessary to establish the validity of evidence or to verify the accuracy of information presented by the individual concerning his or her entitlement, the amount of benefit payments, any review of suspected abuse or fraud, or any concern for program integrity or quality appraisal.

The DoD 'Blanket Routine Uses' set forth at the beginning of OSD's compilation of systems of records notices apply to this system.

NOTE: This system of records contains individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this system of records notice.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING, AND DISPOSING OF RECORDS IN THE SYSTEM:


STORAGE:

Paper records and electronic storage media.

RETRIEVABILITY:

Information is retrieved by case number, sponsor name and/or Social Security Number (SSN) and inquirer name.

SAFEGUARDS:

Records are maintained in areas accessible only to authorized personnel who are properly screened, cleared, and trained. Automated segments are accessible only by authorized persons possessing user identification codes. Security systems and/or security guards protect buildings where records are maintained.

RETENTION AND DISPOSAL:

Paper records are retained in active files until end of calendar year in which they are received, then closed out and held 1 additional year. Then transferred to the Federal Records Center (FRC), the FRC shall destroy after an additional 5 years. Paper copy records that have been converted to electronic, microfilm, imaging or optical formats, the paper copy is destroyed after verification of data, and the electronic, microfilm, imaging, or optical format are kept by the contractor for 6 years after the claim is processed to completion, and then destroyed by cross shredding, macerating, degaussing or by a commercially bonded or insure vendor who must provide a certificate of destruction. The destruction of the records must be witnessed. Destruction of the records is dependent on any records preservation orders that may be in effect.

SYSTEM MANAGER(S) AND ADDRESS:

TRICARE Management Activity, Department of Defense, Communications and Customer Service Division, Skyline 5, 5111 Leesburg Pike, Falls Church, VA 22041-3206.

NOTIFICATION PROCEDURE:

Individuals seeking to determine whether information about themselves is contained in this system should address written inquiries to the TRICARE Management Activity, Department of Defense, ATTN: Communications and Customer Service Division, Skyline 5, 5111 Leesburg Pike, Falls Church, VA 22041-3206; or TRICARE Management Activity Privacy Office, Skyline 5, Suite 810, 5111 Leesburg Pike, Falls Church , VA 22041-3201.

Written requests should include name, Social Security Number (SSN) and dates treatment received.

RECORD ACCESS PROCEDURES:

Individuals seeking access to information about themselves contained in this system should address written inquiries to the OSD/JS FOIA Requester Service Center, 1155 Defense Pentagon, Washington, DC 20301-1155.

Written requests should include name, Social Security Number (SSN) and dates treatment received.

If it is determined that the release of medical information to the requester could have an adverse effect upon the individual's physical or mental health, the requester should be prepared to provide the name and address of a physician who would be willing to receive the medical record, and at the physician's discretion, inform the individual covered by the system of the contents of that record. In the event the physician does not agree to convey the information contained within the record to the individual, TRICARE Management Activity will take positive measures to ensure the individual is provided the requested information.

CONTESTING RECORD PROCEDURES:

The OSD rules for accessing records, for contesting contents, and appealing initial agency determinations are published in OSD Administrative Instruction 81; 32 CFR part 311; or may be obtained from the system manager.

RECORD SOURCE CATEGORIES:

Contractors, congressional offices, Health Benefits Advisors, all branches of the Uniformed Service, congressional offices, providers of care, consultants, and individuals.

EXEMPTIONS CLAIMED FOR THE SYSTEM:

None.

FEDERAL REGISTER HISTORY:

October 7, 2009, 74 FR 51568; November 18, 2013, 78 FR 69076